Patient Referral Form

ORDER SUPPLIES QR CODE ENG
How to refer your patients:
  • Upon completing the form, please use the submit button below to send it directly to our customer care team via email.

  • To have your patients complete the form themselves, please have them scan the QR code or visit www.cathetersplus.com/cathetersplus-order-supplies/

Patient
Product Information - Please select all that apply
Practitioner
Clinician Notes
Prescription Information
INTERMITTENT CATHETERS:

(FR)

INCONTINENCE PRODUCTS:
Red Leaf Medical

For Offline use only.
Please download the PDF below and follow the instructions on the page to refer your patients to our customer care team